Stephenson 1 Grace Stephenson Writing 312, Mary Lee Mental health in developing countries

The first time I met Djarri, I knew there was something different about her. Unlike the other girls of Sanaar Peul, a village on the outskirts of Saint-Louis, Senegal, whose hair was neatly plaited in tight rows, Djarri s was a tangled mess full of Sahel sand and bits of straw and, as we learned later, lice. She clambered for attention and threw herself on my yes, American friends and I, as we seemed to be the only people in Sanaar Peul who smiled at or tried to engage with her as she prattled on in her native Pulaar, the only language she spoke, never having attended the village s French elementary school. She often
Djarri, of Sanaar Peul, Senegal, flashes one of her contagious smiles

lashed out at the other children, who warned us, Elle est folle! They pointed their index fingers, thumbs extended, to their temples and twisted them away with a flick of the wrist: what we quickly came to know as the Senegalese sign for crazy. Goading Djarri on to violent outbursts appeared to be a favorite pastime of the children s, and they often paid for it with a sharp blow to the head or shoulder of surprising force for such a young girl, always accompanied by a fit of laughter.

Stephenson 2 I never learned exactly what was wrong with Djarri, but I suspect her village didn t know either, and probably didn t have the resources to diagnose, let alone treat, whatever psychological disorder she suffered from. Memories of Djarri and other victims of conditions like schizophrenia and bipolar disorder, however, have stayed with me since my return to the so-called developed world. What could be done, I wondered, for these individuals whose suffering had so deeply marked me? The interplay between culture and medicine becomes especially tricky when it comes to mental health that much became clear in the five short weeks I spent in Senegal. Further, even if we can find culturally appropriate ways to deal with mental illnesses in developing countries, the initiatives we push for have to be sustainable, a word that has become so fashionable in development circles for very good reasons. In civil society as well as in academic circles, aid for individuals with disabilities physical and psychological is so commonly seen as a luxury poorer countries simply can t afford. And finally, how can development stakeholders academic development jargon for any group or individual even remotely involved with the problems of development, be that governments, NGOs, members of civil society, research institutions, etc. generate interest and awareness for the need for mental health care?

Does anyone care enough to do anything for the very vulnerable, but from a utilitarian standpoint not very societally useful, mentally ill in the developing world? I should admit from the start that I cannot claim to fully answer any one of these questions. In this piece, I am less interested in proposing specific programs in specific locals, and more interested in raising awareness for the need for mental health initiatives in development policy, and understanding and exposing some of complexities that involves. In the last decade, some key members of the international community have begun to see

Stephenson 3 mental health as a pressing issue in development efforts; however, most of the talk is happening high above the heads of us average folk. So here, for your reading pleasure, I will try to boil down some of the central ideas and arguments to make the problem of psychological disorders and their treatment in the developing world more accessible and digestible. One of the most basic questions we can ask is why we should even care about mental health in low- and middle-income areas. We can argue from the philosophical perspective that protecting and helping individuals with mental illness worldwide is by making it a human rights issue. The World Health Organization (WHO) recently issued a report that called for action on behalf of people with mental health conditions because they are a vulnerable group . In development jargon, vulnerable means something very specific. According to the WHO report, entitled Mental Health and Development: Targeting people with mental health conditions as a vulnerable group, the mentally ill are vulnerable because they are subjected to stigma and discrimination, they experience astronomically high rates of physical and sexual abuse1, their political and civil rights are often jeopardized, their access to health and social services restricted (WHO xxv), and in some rather shocking cases they are chained or caged in squalid conditions in what claim to be treatment facilities2 (Suarez). Because of discrimination it is also much harder for people with mental health conditions to find regular employment, and their access to appropriate schooling is most often limited at best, or non-existent at worst (WHO xxv). Even more,

This is true around the world. One study in the United States found that people with mental health conditions were 11 times more likely to be targets of violent crime (whether completed or threatened) and 140 times more likely to be victims of personal theft. (WHO 10) 2 For more, see Ray Suarez s report on PBS, Indonesia s Mentally Ill Face Neglect, Mistreatment. 18 July 2011. <http://www.pbs.org/newshour/bb/health/july-dec11/mentalhealth_07-18.html>
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Stephenson 4 because all of these factors interplay and amplify the others effects, these people often die prematurely (WHO xxv). These are all violations of basic rights guaranteed by The Universal Declaration of Human Rights, adopted by the United Nations in the years following World War II. However, forward-thinking though the vulnerability and human rights approach may be, and though it may fuel some enthusiasm for the cause, it is probably not enough to generate widespread support from the international community, simply by virtue of the fact that there are so very many vulnerable groups that need their basic rights protected. You can t help everyone whose rights have been violated at least not right away or all at once. We can also frame the question of why mental health initiatives might be important in terms of general physical well being. It has long been clear that the mind-body connection is more than a far-fetched spiritualist idea; a person s mental and physical health are closely intertwined. For example, mental illnesses cluster with health concerns, including heart disease, cancer, and alcohol abuse (Miller 460). The WHO report mentioned above cites similar risks, including higher rates of diabetes, heart disease, stroke and respiratory disease (WHO 25). Further, people with mental illnesses like schizophrenia and depression are also more likely to contract infectious diseases, including sexually transmitted ones (WHO 25), and less likely to complete the complicated treatment process for HIV (Miller 460). And because mental and physical health are so bound up in each other, we get into a messy chicken-and-egg debate about which came first, a mental health condition or a physical ailment? A person with mental illness is less likely to take the best care of her physical health and often has a weaker immune system, and being in poor physical health can trigger mental illness, like the link between HIV and depression

Stephenson 5 that is the subject of significant research in the United States. I would suggest, then, that treating mental illness should be part of standard health initiatives. Let s start to break that cycle. Even more, an individual s mental health affects not only his own physical wellbeing but also his family s and his community s. For example, recent work in Pakistan and India has shown that maternal depression which the study estimates is up to 30% in these regions really hinders child development (Miller 460). A child born to a depressed mother has a lower average birth weight, grows more slowly, is more likely to have diarrheal disease and less likely to get all of his vaccinations. The mentally ill themselves, both in and out of psychiatric hospitals in the developing world, are also on the whole far less likely to be vaccinated (WHO 16), and as we have seen even in developed countries lately, when vaccine rates fall, contagious disease rates soar (Ropeik). And as mentioned above with the link between depression and HIV, so it is with a failure (or outright refusal, as the case often becomes in many developed countries) to receive a full set of vaccinations: one person s risky behavior puts an entire community at risk. (Disregard or don t the implication that those who refuse vaccinations are mentally ill.) Improving the mental health of individuals can improve the overall health of communities. The most central reason to help people who suffer from mental health conditions, at least in my opinion, is also probably the most controversial. Around the world, people tend to assume that the mentally ill can t contribute meaningfully to society (WHO 15). The mentally ill, we say, are a financial burden. In this line of reasoning, it follows that directing aid money to mental health initiatives in the developing world is worthless because we will never see a return on those investments. Florence Baingana, a Ugandan psychiatrist, who

Stephenson 6 advises the World Bank, explains that there is not enough evidence to recommend investments in mental health services in poor countries (Miller 461). Put simply, our attitude is that treating mental illness in the developing world isn t cost-effective. However, in the last decade key research groups have started setting up low-cost mental health interventions in low- and middle-income countries, particularly for people who suffer from depression. For example, in 2003 researcher Paul Bolton did a study in Uganda in which over a period of 16 weeks, villagers with depression attended weekly group therapy sessions with a local village health worker who had two weeks of intensive training. At the end of the study, the group that had attended therapy sessions experienced significantly fewer and less severe symptoms than the control group s cases of spontaneous recovery (Miller 460). The same year, two other studies independently found similar results that there are inexpensive ways of adapting certain kinds of therapies, especially group therapies, to the needs of the developing world (Miller 460). Psychiatrist Vikram Patel, who specializes in mental health in the developing world, argues that financial constraints, including the dearth of mental health professionals and psychiatric hospitals, mean that developing countries can t simply mimic treatment programs in the West like hours of psychotherapy and combinations of expensive drugs (Patel). Rather, programs launched in poor areas should adapt treatment to their budget, which some, like Paul Bolton, have suggested should focus on group therapies, supplemented with medical help where feasible and appropriate. It has also long been clear that mental illness is linked to poverty. The relationship between poverty and mental illness is often quite similar to the interplay of mental and physical health described above. Poverty often means substandard living conditions,

Stephenson 7 limited access to primary health care, and fewer chances of educational and employment3 (WHO 29). These factors put people at a higher risk for developing a mental illness, and that means even less opportunities for education and employment, that they are even less likely to get needed treatment, and more likely to live in poverty (WHO 29). For these reasons, psychological disorders can cluster in poor areas, so treating mental health in the developing world is helping to break the cycle of poverty. If we can get people who suffer from mental illness healthy enough to get back to work, we can activate a previously untapped workforce. Of course, here we have to acknowledge that some employers may not want to hire a person with a mental health condition. A family friend, who for privacy s sake I ll call Julie, is on disability assistance because her severe depression and other psychological issues mean she struggles to hold down a job. Julie wants to work, and in fact would love to teach children with disabilities she even began taking classes at the local community college to do so. Yet she often fails to show up for class or work because of a bout of depression and then finds herself jobless again. Employers in developing countries would be understandably skeptical when taking on higher-risk employees. Still, helping the mentally ill find stable work they are capable of performing is hardly impossible. In the whole, the untreated mentally ill are a major financial burden, and as Florence Baingana explains, Convincing the skeptics will require demonstrating the economic costs of untreated illness more clearly and countering the persistent view that a person with a mental disorder will never function at a normal level (Miller 461). In the next few years as mental health initiatives gain ground in the developing world, it will become ever more
In fact, worldwide, people with a mental health condition experience an incredibly high rate of unemployment: between 70 and 90%, the WHO estimates (WHO 21).
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Stephenson 8 important to show that people with psychological disorders can return to work and contribute in meaningful ways including financially to their communities. BasicNeeds, an NGO that employs people with mental health conditions on community farms, is making headway in this direction. The WHO report explains that on a BasicNeeds farm, people with mental illnesses raise crops and ornamental plants, and the profits from the sales of these items are first shared among the group and then reinvested in the farm for new tools and repairs (WHO 47-48). The farm workers also participate in regular, community-based treatment (BasicNeeds). BasicNeeds combines effective treatment with income generation, because [s]ustainable livelihoods create sustainable recoveries (BasicNeeds). Ultimately, it is important to help people who suffer from mental illness because, with affordable treatment, they can help their communities. Perhaps someday we may even realize that it s not that we cannot afford to help people with mental health conditions, but rather that we cannot afford not to. Now that we have explored some of the reasons why mental health initiatives may be important, we need to suggest some general guidelines for what they should look like and aim to do. First, although it seems an obvious criticism, any development initiative needs to be appropriate, that is, able to meet a real need and do so in ways that are effective, efficient, and suitable for a given group of people. For this reason, it is of vital importance to begin by identifying mental health needs by region. Rates of various mental illnesses will vary by population, as does the availability of treatment. For example, in areas with significant inbreeding, there is often a higher incidence of congenital mental retardation, while large Western cities may have higher rates of severe depression. What, then, is the situation on the ground? The answer is that we need more answers. We do

Stephenson 9 have some data on rates of various disorders, but there are not enough. This is why we need more institutions like the World Mental Health Survey Initiative, a research group that gathers and analyses epidemiological data on mental illness and substance abuse. But simply gathering more information in this way is still not enough. As I have tried to gather more information on current progress in mental health treatment on a global scale, I ve been struck by the comparative lack of concern for the cultural sensitivity psychological and psychiatric treatment requires. Sometimes it may be the case that treatment techniques we use in the West will not be very successful in the developing world, and not only for financial reasons. There are a lot of cultural stigmas and, forgive the rather imperialistic term, superstitions to overcome in dealing with mental illness in many developing countries. Djarri of Sanaar Peul was definitely stigmatized in her social interactions with other village children. (Remember that hand gesture?) In Indonesia, for example, many people believe psychological disorders to be the result of evil spirits rather than a physical (that is, neurological) problem, and combine massage, prayer, and herbal remedies like eye drops and coconut drinks to treat patients (Suarez). Similarly, in Afghanistan, mental illness is often thought to be caused by djinns, witchcraft, the evil eye malicious supernatural forces (WHO 9). In Thailand, a predominantly Buddhist country, people sometimes chalk psychological disorders up to karma (WHO 12). In Somalia, traditional healers devised the so-called hyena cure : the person suffering from a mental illness is thrown in a pit with hungry hyenas to frighten out the evil spirits (WHO 12). Yet however backwards and laughable such beliefs and practices may seem to us, we in the West also need to recognize that we know far less about the mind and its apparent dysfunctions than we think we do. We think we can easily match patient

Stephenson 10 symptoms to those described in the psychologist and psychiatrist s bible, the Diagnostic and Statistic Manual of Mental Disorders, or the DSM-IV, and treat and cure accordingly. As author Ethan Watters points out in his book Crazy Like Us: The Globalization of the American Psyche, we have created a closed canon of possible mental disorders and refuse to allow for diversity of symptoms and even disorders. How can we effectively help people with psychological disorders if are only trying to understand them within our own, very cultural, understanding of the mind? As we try to grapple with the problem of mental health in the rest of the world, we need to be willing to reexamine our own conceptions. One of Watter s central theses is that the tendency of American psychiatry to attribute mental illness almost entirely to neurological imbalances brain diseases

affixes as much stigma to those who suffer from it as does the belief it s caused by evil spirits. I think we can chalk this up to Western materialism basically, the belief that all things can be explained by physical causes, and by extension that we humans are nothing more than a complex network of impulses and influences and genetic factors just waiting to be unraveled. If an individual is mentally ill simply because he has a neurochemical imbalance, it may seem at first glance easier to erase stigma because his disorder is not his fault. However, this materialist perspective leaves a narrow margin for healing, and emphasizing the perceived biomedical roots of mental illnesses has not decreased stigma because at least on some level it makes us equate an individual s identity with his disease. In a piece in The New York Times Magazine, Watters cites several studies in developed countries, including the U.S., Germany, Turkey, Russia, and Mongolia, that have shown people s mistrust of and desire to maintain distance from people with schizophrenia has increased with time, rather than decreased. Watters explains, It turns out that those who

Stephenson 11 adopted biomedical/genetic beliefs about mental disorders were the same people who wanted less contact with the mentally ill and thought of them as more dangerous and unpredictable (Watters Americanization ). So much for reducing stigma. Even more, American cultural patterns for interacting with people who suffer from mental health conditions need to be scrutinized. Because of persistent stigma, people with mental illness are still marginalized in the West and often increasingly isolated from the group. Although this is probably also the case in many parts of the developing world, anthropologist Juli McGruder has found that among Swahili Muslims in Zanzibar, cultural beliefs that what we identify as schizophrenia is caused by evil spirits actually help the mentally ill in two key ways. First, as Watters explains, Since the illness was seen as the work of outside forces, it was understood as an affliction for the sufferer but not as an identity, the opposite of the Western materialist tendency that allows less room for healing. Second, they maintain a place in their families and communities. Members of the sufferer s kinship group try to coax out evil spirits with food and goods and song and dance, thus performing small acts of kindness for the schizophrenic (Watters Amerianization ). The individual is still an important part of his group and knows it. This lesson the value of community in helping those that suffer with mental illness was the one I drew most from my time in Sanaar Peul. Although the other children teased Djarri and at times were visibly frightened by her fits of violence, she had a place in the village. She was fed, clothed, and cared for by her family and the extended kinship group. I never saw her alone she was always accompanied by a group of younger girls who had learned to dodge when she struck, and sometimes some of the older children would explain to us in French what Djarri was trying to tell us in Pulaar.

Stephenson 12 In dealing with mental health in the developing world, Americans need to recognize that we do not have all the answers. While I can suggest some basic ideas I think will be helpful in specific development initiatives, like building on the community spirit of the people of Zanzibar to their schizophrenics or teaching social interaction and marketable skills to empower the mentally ill, the most important idea is our own humility. How much do we really know about the way psychotropic drugs affect the mind? Probably not enough to export them wholesale to the developing world. How useful is the American conception of the mind to understanding the way mental health conditions should be treated elsewhere? Perhaps, since our recovery rates are often lower than in some developing countries, it needs to be reconsidered. I am not trying to suggest that since the question of mental health initiatives in the developing world is complicated we should abandon it hardly so. Instead, I believe that as we rethink the way we approach mental health abroad, we will learn many valuable lessons about how to approach mental illness at home. This means funding studies in psychiatric epidemiology to figure out what disorders exist where, conducted with sensitivity to how they may differ from the DSM-IV s prescriptions. It also means funding cultural studies like Juli McGruder s anthropological work in Zanzibar that will more than likely shift our attitudes toward mental health, helping us identify the strengths and weaknesses of conceptions of the mind and how to treat its malfunctions both at home and across the world.